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A40 182-��pson County Health Department Sewage System Improvements Permit Da:e: `��"�� ,This Permit Void After 5 Years Pe it #�-�'7 -Z DD� Owner: '. '' O�iy � I' ?� �� +-� SR# _��—�— L.ocation/Directions: � u j-� Subdivision Name: � � ''� ' � � � ' � - ''`'a � � Lot #� Lot Size: << � Type of Dwelling: Water Supply: Private: �Y✓� Pablic: Community: Bedrooms: 3 --Ciarbage Disposai Basement Basement F' ures INFORMA (�R D BY Sanitarian: � ') er or re��c�u�e REPAIIt: REEVALUATION: � --- Size of Septic Tank: —��— gallons Size of Pump Tank: Nitrification Line: 1. �i �1 �� Depth of Stone: 12 inches Max Depth of Trenches: Altemative System: Conv. Pump LPP Pump Remarks: Date Well Approved: Well should be 100 f� from any sewer system BY Sanitarian � 2� . � � Date ag Sy te roved: BY Sanitarian CA OF COMPLETION ,.,3 Contractor. ` � -------- --------------- � Sewage System location. installation, and protection must meet state and local � regulations. Septic tanlc should be pumped out every 3 to 5 years and shall be maintained by owner in such manner as not to create a public health hazard. Septic tank and nitrification line must be inspected and approved by a member of the Person County Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this pemut is subject to revocation. (G.S. 130 A-335F) Location of sewage disposal sewage system sketched on back. (OVER) NOT'E: ,�Viake sketch of installation showing lot size and shape, location of house, septic tanks, privies, water , Supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located ,�t later date. Note location of water supplies on adjacent lots. �a � (X) i (2) � � � �� ` 1 �� ou..� .�-cs�ic � -'` �"erson County Health � Well Permil bate:� This Permit Void After 5 Years Owner. Department Subdivision Name: • ' ' � — Drilling Contractor: __ _ WELL CONSTRUCTION Distance from Nearest Properry Line Distance from Source of Pollution Total Depth: FG Yield:�_ GPM Static Water Level Ft Water Bearing Zones: Depi�i FG � Casing: Depth: From C,.� to Ft. Diam�et�r Tnches TYPE: Steel GalvanizedSteel✓ � If Steel, does owner approve�No WeighG Thickness: Height Above Ground: Inches Drive Shoe: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason: �� / Grout: Type: Neat Se�d/Cement Concrete Annular Space Wid[h�_Inches Water in Armular Space: Yes No Method: Pumped Pressure Poured � Depth: From �—to Ft Materials Used: No. Bags Portland Cement Weight of 1 bag_lbs. If mixture (sand, gra el, cuttings) - Ratio: to ID Plates: Yes No 4 x 4 slab Yes �/ No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED ] FORTH BY THE PERSON COUNTY Sketch well location on reverse side. Sanitarian's Signature Date Completed � � � '� � � cu � ��NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water �upplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be ,Aocated at later date. Note location of water supplies on adjacent lots. � . �\ .. �'� � , .�,�; � , + ��rson County Health Department �j> Well Permit Date:O --�b " t '�'his Permit Void After 5 Years �,� Owner �,.s^.�.+�.�? (_� � �,, e � !d- SR# �.� Subdivision Name: , Lot # Drilling Contractor: WELL CONSTRUCfION Distance from Neazest Property Line Distance fmm Source of Pollution Total Depth: F� Yield: GPM Static Water Level Ft Water Bearing Zones: Depth Ft. Ft. Ft FG Casing: Depth: From to Ft. Diameter: Inches TYPE: Steel Galvanized Steel If Steel, does owner approve: Yes No Weight: Thickness: Height Above Ground: Inches Drive Shoe: Yes No Were Problems Encountered in Setting the Casing? Yes No If "yes" give reason: Grout: Type: Neat Sand/Cement Concrete Annutar Space Width Tnches Water in Annulaz Space: Yes No Method: Pumped Pressure Poured Depth: From to Ft Materials Used: No. Bags Portland Cement Weight of 1 bag_]bs. If mixture (sand, gravel, cuttings) - Ratio: to ID Plates: Yes No 4 x 4 slab Yes No I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT. Sig� e o� Contractor � ' Date (,�%r,u�-�� %j � A L�,,; �-�f - y � Sanitarians Signafu e v DateIssued Sanitarian's Signature Date Completed Sketch well location on reverse side. 'd �S' n cu � 'b � � r' � N TE: fVlake sketch of installation showing lot size and shape, location of house, septic tanks, privies, water s �lies, etc. Note special problems existing on lot. Write in measurements in order that installations may be 1 ted at later date. Note locadon of water supplies on adjacent lots. (i) �2� � I , .� � I -- - • h � �� . .a �,�?��; � � ��" . �I �y �� 1. Permit requested by�.,J�J�n+.� Addres s : � .,al \ � �.-Q-2,�� APPLICATIOK FOR It�ROVBiENT PERliIT DATE: 2. tlame and address of current owner: 3. 4. Home Phones��" `�fl� Business Phone .. � Property Description: Lot size �•S'� `�""�"' • Dimensions: Front Left Right Rear �id� -��' �o.��..�! Block No. Lot No. Tax map N To�+nship: 5. Directions to property: State Road No. & Road Na^�es, etc. 6. Psrmit requested for: New Installation " Repaired Additional Renovation re-using present system 7. Number of occupants of people served 8. Disnensions of Proposed Structure: Width Depth 9. What tyge.(if any) additions, expansions, or�replsc��ent is �ziicipated te the structure or facility that this seWage disposal sys�em is intend to serve? .10. Type of water supply: Well�/ yes no: If no, name source of �.rater supply: .. Are there any Frells on adjoining property? If so, identify location. N-.�� S^�s"t S�-� 11. Type of structure or facility: Proposed� Existing Type of dwelling: House Niobile Hom�Business Type of business Number of Employees_ Number of Bedrooms � Number of automatic appliances Sasement . Number of basement fixtures 12. Clearly stake sll carners of the property snd the corners of all proposed structures. I hereby make application to the Person County Health Department for a site evaluation or existi.ng system evaluation for the on-site sewage disposal spstem for the above described property. I agree that the content of this application are true and represent the maxi.mum facilities to be placed on the propertp. I understand if the site is altered or the in- tended use changes, the permit shall become invalid. Permits are valid for 60 months from date of issLe. Permission is hereby granted to enter the propertp for the evaluation. G.S. 130A-335(F) . Owner or ed Agent 0 FACTORS - SITE EVALUATION 1. SLOPE (%) 2. SOIL T�XT'JRE (i2-36 in.) (Sandy, loamy, clayey, Note 2:1 clay) 3. SOIL STRUCTURE (12-36 in. (Clayey soils) 4. SOIL DEPTH (in.) S. RESTRICTIVE HORIZONS (in.) (Impervious Strata, rock) 6. SOIL DRAINAGE/GROUNDWATER (External & Internal) 7. SOIL PERMEABILITY (Percolation Rate) S PS U S PS U S PS U S PS U S PS U S PS U S PS U S AREA 1 S PS U S S PS U S PS U S PS U S PS U S PS U S AREA 2 0 S PS U S PS U S PS U S PS U S PS U S PS U S PS U S ..� � S PS U S PS U S PS U S PS U S PS U S PS U S PS U S �TLEA 4 8. OTHER (specify) PS PS PS PS � U U U U 9. SITE CLASSIFICATION (See below) SOIL SERIES S- Suitable PS - Provisionally Suitable �.0 - Unsuitable RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) t.°� �6-I�-9� �� a��,� �$�� .... . . . � .. . t� e �''�_ _ � �% APPLICATION FOR SERVICES _ _. Services Requesfed: _ Improvements Permit (Established/Recorded Lot) _ Reinspection of Existing System (Loan Closing) a w � a z Improvements Pernut (Unrecorded Lot) Permit (Mobile Home Replace) Permit (Addition) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well 1. Permit requested by: 7. Dimensions or Proposed Structure: " owner/prospective owner/agent: Width: ��} X �<( C?� S-� o�Q� ddress: eo�ca Ca.rver, �h-- Depth: �� ' � ��` �'`� v�� O' 8. What type (if any, additions, expansions, o o b0 k- � C-- � replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? ome Phone #: .� 9 7- 803 9 usiness Phone #: � 2. Name and address of current owner: 9. Water su type: S�n � private public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No ❑ If so, identify location: 3. Property Description: Lot size: 1,� g � �- . Tax Map#: �� n V�l- � 10. Type of structure/facility: Proposed: DExisting: ❑ Parcel#: 1 g� r �o�+ Type of dwelling: Township: �1 a� le � V e� �� House: ❑ Mobile Home: ❑ Business: ❑ 5. Directions to property: State Road #& Road Type of business: ames, etc. Number of Employees: S�- j�'� �S � Number of bedrooms: Garbage Disposal? Yes ❑ No ❑ Basement? Yes ❑ No ❑ If so, # of basement fixtures: 6. Number of occupants or people to be served: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND TH� CUKN�x� ur� ALL PROPOSED STRUCTURES. I hereby make application to the PersOn COunty Health Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept. within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. Signed Owner or A.iithorized Agent i, m n. •} • Permit Issued ❑ Signature Permit Denied ❑ Plat Observed ❑ r. . r..,,, t� • .. Date r _ . ,. fACTORS-51'I'E EVAi.VATION AREA 1 AREA 2:: AREi13 ^ AREA d.; ___ _:: 1. SLOPE(%) S S S �� S PS PS PS PS U U U U 2. SOIL.TEXNRE(12-36IN.) S S S S (SANDY, LOAMY. CLAYEY. NOIE 2:1 CLAY) PS PS PS PS U U U U 3. SOIL STRUCIl1RE (12-36INJ S S S S (CLAYEY SOiLS) PS PS PS PS U U U U 4. SOIL DEPTH (LY.) S S S S PS PS PS PS U U U U 5. RES7RICI7VEHORIZONS(IN.) 5 S S S (IMPERVIOUS STRATA. ROCK) PS PS PS PS U U U U 6. SOII, DRAINAG&GROUNDWA'[ER S S S S (EXTERNAL & INTERNAL) PS PS PS PS U U U U 7. SOII. PERMEABILI7Y S S S S (PERCOLOA'I'ION RAIE) PS PS PS PS U U U U R. AVAILABLE SPACE S S S S PS PS PS PS U U U U 9. SI7'E CLASSIFICATION(SEE BELOW) SOIL SERIES S•SUtYABLE PS-PROVISIOIVALLY SUITABLE U•UNSUI'fABLE RECOMMENDATIONS/COMMENTS: SITE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:�AMiPRO\DOCSAPPSEC.SMFINANCE.PC � i � c� a � � PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # � �f-0 Parcel # 1 $�— Zoning Township �-�� 'As Owner/Contractor �' Date > o --�� l S Location/Address 4'� P�%� �-,n�c�� ` --�-�`E'� � � ' S.R.#�-. �s�.�2,av.��1 �i� bdivision N . 1 � � ��1 I � � •� � � � /� �� .' � � / � " � . � � , / � Lot# As Installed � . SEWAGE SYSTEM 5PECIFICATIONS Repair Lot Area �, �� Size of Tank �d-�- SFD,�/ Mobile Home t� Size of Pump Tank Business # of Bedrooms�_ Nitrification Line � d o�X 3 Max Depth Trenches Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is al�ered or intended use chan ed� Well and Septic Layout by p��-sti.,=�� ti ��'�� '«� Comments: Date 6� ' Installed by „ _c,,._i __.��. ell Permit iblic te Appr � 'ell He d routi A Date Instal WELL ni-Publi SPECIFICATI 3 by trl..r� -�'.-�-�„� Required Sl _ Air Vent Required ell Log Well T by, This report is based in paR on information provided the homeowner or his/her representative in the application submitted for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental hea►th specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resuited from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wairants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\pettnit.sam O1/95 rev.1.0